Adult Audiology —
Training activity: 2

Details

Assess and manage patients who require tinnitus and/or hyperacusis support in a routine adult clinic

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Information counselling and patient education on epidemiology and causes
• Principles of patient-centred care
• Impact on the patient
• Validated questionnaire measures
• Shared decision-making
• Communication skills and patient-centred care
• Use of interpreters
• individual management plans
• Management with hearing devices
• Scope of practice
• Onward referrals
• Screening tools
• Patient pathways
• Local and national guidance, and international best practice

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

• What does success look like?
  • What are the expected outcomes for successfully assessing and managing patients requiring tinnitus and/or hyperacusis support in a routine clinic setting?
  • What does successful application of knowledge about the pathophysiology, assessment, and management of tinnitus and hyperacusis look like in practice?
• What is your prior experience of this activity?
  • What is your existing knowledge and prior experience regarding the assessment and management of tinnitus and hyperacusis?
  • What specific challenges might you anticipate when assessing and managing patients with tinnitus and/or hyperacusis (e.g., complex presentations, psychological impact, managing expectations)? How will you prepare to handle these challenges?
  • Do you recognise the scope of your own practice for supporting patients with these conditions?
  • Do you know when you might need to seek advice, refer, or escalate, and from whom?
• What do you anticipate you will learn from the experience?
  • What specific skills related to the assessment or management of tinnitus and hyperacusis do you aim to develop during this activity?
  • What specific insights do you hope to gain about the patient experience of tinnitus/hyperacusis or effective support strategies?
• What additional considerations do you need to make?
  • Have you reviewed any feedback or identified actions for development from previous experiences with similar cases?
  • What important information do you need to consider about the patient or their presentation before the appointment (e.g., co-morbidities, complexity of their audiological profile)?

In action

• During the activity is anything unexpected occurring?
  • Are you noticing anything surprising or different from what you anticipate during the assessment and management of tinnitus and/or hyperacusis? Are you encountering situations such as:
    • The patient reporting highly atypical or complex symptoms (e.g., pulsatile tinnitus with no vascular explanation, or hyperacusis accompanied by severe phonophobia) that deviate from routine presentation?
    • The patient displaying extreme emotional distress, anxiety, or panic related to their symptoms, which impacts their ability to engage with the assessment?
    • Unexpected difficulties arising in the objective verification of hearing status (if applicable) that complicates the development of the tinnitus/hyperacusis management plan?
    • The patient immediately and strongly rejecting the proposed management strategy (e.g., Tinnitus Retraining Therapy principles, sound enrichment) due to preconceived notions or misinformation?
  • How does this experience compare with previous experiences of similar activities?

• How are you reacting to the unexpected development?
  • How is the unexpected development being resolved as you progress during the activity? How do you work within your scope of practice (e.g., identifying when onward referral for psychological or medical assessment is necessary)?
  • What are you learning in this moment as a result of the unexpected development? For example, are you learning more nuanced questioning techniques to assess distress levels, or a more robust method for presenting the evidence base for sound therapy when faced with scepticism?
  • How is this impacting your actions?
    • Are you responding to the situation appropriately? Are you adapting or changing your approach to the procedure (e.g., modifying the assessment battery, or simplifying complex management principles)?
    • Is this unexpected event affecting your ability to undertake the activity independently?
    • Specifically, are you immediately using active listening and validation techniques to address patient distress, or are you adjusting the complexity of the management discussion based on the patient’s current mental state?
  • How are you feeling in this moment? For example, are you finding it difficult to adapt? Is it affecting your confidence in managing complex auditory symptoms? Are you feeling positive you can reach a successful conclusion?
• What is the conclusion or outcome?
  • How do you work within your scope of practice? E.g., Did you successfully develop an individualised management plan based on your understanding of the pathophysiology of tinnitus and hyperacusis, even when faced with atypical symptoms?
  • Did you work within your scope by immediately identifying when onward referral for specialised psychological or medical assessment is necessary due to extreme emotional distress or complex symptoms that go beyond routine audiology management?
  • What do you learn as a result of the unexpected development? E.g. Did you learn more nuanced questioning techniques to assess distress levels and to address patient anxiety during the assessment.
  • Did you gain a more robust method for presenting the evidence base for management options (like sound therapy) and handling scepticism or rejection of the proposed strategy?

On action

• Begin by summarising the key points of how you assess and manage a patient requiring tinnitus and/or hyperacusis support.
  • Consider specific events, actions, or interactions that feel important, such as gathering specific symptom history, conducting pitch/loudness matching, or discussing the evidence base for management options (e.g., sound therapy). How do you feel during this experience?
  • Include any ‘reflect-in-action’ moments where you adapt your questioning or management approach as the assessment or counselling unfolds.
• Identify what learning you take from this experience regarding tinnitus and hyperacusis support.
  • What strengths do you demonstrate (e.g., detailed history taking, confidence in presenting evidence-based management, empathy)?
  • What skills and/or knowledge gaps are evident (e.g., advanced use of psychometric questionnaires, deeper understanding of specific pathophysiology, or knowledge of interagency support)?
  • Compare this experience against previous similar engagements. Have any previously identified actions for development been achieved? Has your practice in managing tinnitus/hyperacusis improved?
  • Identify any challenges you experience (e.g., patient distress or panic, atypical symptoms, or strong rejection of management strategies) and how you react to these. Does this affect your ability to deal with the situation? Are you able to overcome the challenges?
  • Identify anything significant about this activity, such as needing to seek advice or clarification on complex management options or onward referral pathways.
  • Acknowledge any changes in your own feelings now that you are looking back on the experience.
• Identify the actions or ‘next steps’ you now take to support the assimilation of what you learn, including from any feedback you receive.
  • What will you do differently next time you assess and manage a patient with tinnitus or hyperacusis?
  • Has anything changed in terms of what you would do if you are faced with a similar situation again?
  • Do you need to practise any aspect of assessment or management further?

Beyond action

• Have you revisited your previous reflections (reflect-before-action, reflect-in-action, and reflect-on-action) for this specific activity – assessing and managing tinnitus and/or hyperacusis?
  • When reviewing these past reflections, what actions for improvement did you previously identify you would need to take to improve your practice related to understanding the pathophysiology of tinnitus and hyperacusis, applying evidence-based management approaches, or addressing patient emotional distress?
  • Have you completed these previously identified actions? If not, what are the barriers? If so, how did completing them impact your subsequent performance of this activity? Are you ready to demonstrate this new learning confidently and consistently when performing this task?
  • Have you engaged in professional storytelling or discussed your experiences of tinnitus/hyperacusis support with peers, near peers, or colleagues? Has discussing these experiences with others changed your view or understanding of management approaches (e.g., hearing therapy), interagency support available for complex patients, or strategies for managing highly anxious patients?

• Considering your cumulative experiences and reflections on this activity, how does the learning you have gained support you in preparing for relevant observed ‘in-person’ assessments for the module?
• How has your practice related to assessing and managing tinnitus and/or hyperacusis developed and evolved over time across multiple instances of undertaking this ETA?
  • Can you identify specific examples of improvement or increased confidence in selecting appropriate diagnostic techniques (e.g., TEN test), synthesising test results with history, or creating individualised, evidence-based management plans?
• Based on your experiences, how has your ability to recognise when something related to tinnitus/hyperacusis management is beyond your scope of practice improved?
  • Do you have a clearer understanding of when and from whom (e.g., supervisor, ENT specialist, psychological therapist) you need to seek advice or clarification regarding atypical or complex symptoms (e.g., suspected vascular issues) or severe co-morbid mental health conditions?

Relevant learning outcomes

#	Outcome
# 1	Outcome Use a range of tests to safely assess the extent and nature of auditory problems in adults, including those with complex aetiologies, complex audiological configurations and comorbidities.
# 2	Outcome Apply shared decision-making to develop an individualised management plan and counselling for adults with hearing loss and other auditory difficulties, taking into account differing cultural and social attitudes to hearing care.
# 3	Outcome Evaluate individual patient outcomes and safely manage a range of routine and complex hearing losses.
# 4	Outcome Practice within their own personal and professional scope, identifying where onward referral is appropriate.